Hiatal Hernia (HH)

A hiatal hernia is a condition that develops as a result of protrusion of the stomach wall into the mediastinum through an enlarged esophageal hiatus of the diaphragm, impairment of the function of the gastroesophageal sphincter, reflux of acidic gastric contents into the esophagus, and their adverse effect on the esophageal mucosa.

Hiatal hernia (HH) is closely associated with the concept of gastroesophageal reflux disease (GERD). GERD is a chronic relapsing disease caused by the retrograde reflux of gastric juice into the esophagus and/or extraesophageally.

The development of a hiatal hernia is promoted by: heavy physical work, persistent constipation, coughing, prolonged work in a bent position, overeating followed by the patient assuming a horizontal position, and other conditions associated with increased intra-abdominal pressure.

These factors lead to the enlargement of the opening in the diaphragm, through which, with increased intra-abdominal pressure, the initial part of the stomach moves beyond the abdominal cavity. At the same time, the valve function of the gastroesophageal junction is impaired, and reflux of acidic gastric contents into the esophagus occurs.

Main manifestations of hiatal hernia:

Approximately half of cases of hiatal hernia are asymptomatic or accompanied by mild clinical manifestations.

Retrosternal pain and heartburn are the most characteristic symptoms of gastroesophageal reflux disease and hiatal hernia. Heartburn intensifies at night, after meals (especially with large food intake, consumption of carbonated beverages, watermelon), during physical exertion, and when working in a bent position.

The intensity of heartburn and retrosternal pain increases when attempting to lie down after eating, as well as during work in a bent position.

Other common manifestations of reflux disease include belching and regurgitation of gastric contents (spontaneous expulsion of stomach contents into the esophagus).

Retrosternal pain (non-coronary cardialgia) is often observed and may be mistaken for angina pectoris or myocardial infarction.

In one-third of patients with hiatal hernia, the leading symptom is cardiac rhythm disturbance in the form of extrasystole or paroxysmal tachycardia.

These manifestations often lead to diagnostic errors and prolonged ineffective treatment by a cardiologist.

How is the diagnosis confirmed?

The diagnosis of GERD and hiatal hernia is confirmed using instrumental methods of investigation, including esophagogastroduodenoscopy and specialized radiological examination.

What are the complications?

With a long course of reflux disease, transformation of the cellular structure of the esophageal mucosa occurs, leading to inflammation, erosions, ulcers, and bleeding.

Due to chronic bleeding from the esophageal wall, posthemorrhagic anemia develops.

With prolonged course of peptic ulcers of the esophagus, their perforation is possible.

Scarring and narrowing of the esophagus in the lower segment lead to difficulty in swallowing and the development of cicatricial stenosis of the lower third of the esophagus.

When gastric contents enter the respiratory tract, tracheobronchitis, bronchial asthma, and aspiration pneumonia may develop.

In severe cases, partial or complete strangulation of the stomach wall or another abdominal organ may occur.

The most serious complication of GERD is Barrett’s esophagus. In advanced cases, esophageal malignancy may develop.

Esophageal cancer is associated with a low five-year survival rate not exceeding 11%.

Patient survival depends on the stage of the disease, with early invasion of the organ wall and metastasis being unfavorable features, which may occur long before the first clinical symptoms appear.

Approximately 95% of esophageal cancer cases are diagnosed in patients with Barrett’s esophagus; therefore, diagnosis and effective treatment of Barrett’s esophagus play a key role in prevention and early detection of esophageal cancer.

Attention!

If the cause of gastroesophageal reflux disease is a hiatal hernia, the effect of medical treatment will be temporary and ultimately ineffective.

Attention!

In case of pronounced clinical manifestations of gastroesophageal reflux disease or hiatal hernia, it is essential to consult a surgeon.

Surgical treatment

Surgical methods aimed at preventing pathological reflux may be considered in cases of low effectiveness of medical therapy.

Indications for surgical treatment also include complications of GERD: recurrent bleeding from esophageal ulcers, peptic strictures of the esophagus, and Barrett’s esophagus with high-grade epithelial dysplasia.

Surgical treatment is appropriate in cases of GERD combined with bronchial asthma and frequent aspiration pneumonia.

Operative treatment is considered optimal in young patients with GERD.

Long-term results of surgical treatment are comparable to those achieved with proton pump inhibitor therapy.

Surgery may be a reasonable alternative to medical therapy for GERD.

Surgical treatment is performed for large hiatal hernias, especially when they are associated with difficulty in food passage and/or reflux of food from the stomach into the esophagus, a high risk of strangulation, or when complications have already developed, as well as in cases of anatomical insufficiency of the lower esophageal sphincter of the diaphragm.

The operation is aimed at creating conditions that prevent gastric contents from entering the esophagus.

The global standard of care for such patients involves laparoscopic surgical intervention with minimal abdominal wall incisions.

During the operation, the normal anatomical relationship between the stomach, esophagus, and esophageal hiatus of the diaphragm is restored.

The esophageal hiatus is narrowed to normal size.

Using several sutures, an anti-reflux wrap is created, which prevents reflux of gastric contents into the esophagus.

Endoscopic (laparoscopic) procedures are well tolerated by patients and allow reduction of hospital stay to 2–3 days.

The use of ultrasonic dissectors, endoscopic suturing devices, and modern mesh materials allows successful endoscopic treatment even of the most complex hernias.